Transcript Telemedicine in Nursing Homes

Telemedicine in Nursing Homes
Murthy Gokula, M.D., C.M.D
Associate Professor/Program Director(Geriatrics fellowship)
University of Toledo
Objectives
• Understand telemedicine
• Discuss telemedicine to reduce hospitalizations
in the nursing home
• Understand STAY HOME project
• What will we be using?
What is Telemedicine?
•
Telecommunications technology + Medicine =
Telemedicine
Telemedicine…How does it work?
Telemedicine uses an audio-visual technology to render healthcare services from a remote
location.
Another way of looking at it...
Tele health and Hospitalizations for
Medicare Home-Healthcare patients
• For both home health agencies and Medicare administrators, the
problem of how to reduce hospitalization rates to improve quality of
care for home healthcare patients continues to be a significant
challenge.
• Moreover, provisions in the Patient Protection and Affordable Care
Act (PPACA) of 2010—which call for the development and adoption
of value-based and bundled payment systems— will require new
community-based health management approaches to reduce
hospitalization rates and deliver high-quality, patient-centered care.
• One of the provisions: Telemedicine - cost effective solution for
disease management.
Issue with hospitalizations
• Its prevalence: ≥15% of long-stay NH residents are
hospitalized within any given six-month period.
• Approximately 40% of nursing home–hospital transfers
have been deemed inappropriate, meaning that the
resident could have been cared for safely at a lower level
of care.
• $$$ Costly $$$
Grabowski, David; O’Malley, James; and Barhydt, Nancy. The Costs And Potential Savings Associated With Nursing Home Hospitalizations. Health
Affairs. November 2007 26:61753-1761; doi:10.1377/hlthaff.26.6.1753
More Issues with Hospitalizations
They are often associated with negative health outcomes:
• Falls
• Incontinence
• Dehydration
• Adverse drug events
• Iatrogenic disease
• Delirium
20 CMS conditions for avoidable
Hospitalization
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Acute Renal Failure
Altered Mental Status
Anemia
Asthma
C. Diff
Cellulitis
CHF
Constipation / Impaction
COPD
Diarrhea / GE
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FTT
Falls and Trauma
HTN
Pneumonia
Nutritional deficiency
Poor glycemic control
Psychosis
Seizures
Skin Ulcers
UTI
Can telemedicine keep NH residents out of
the hospital?
• YES! It also reduces health care costs, according to a study in the Feb 2014 issue of
Health Affairs.
• Researchers from Harvard and Dartmouth universities studied 11 nursing homes in
Massachusetts. They contracted with a telemedicine provider to cover urgent or
emergent calls on weeknights and weekends.
A medical secretary at the telemedicine service answered the after-hours calls and
referred residents to a staff nurse, nurse practitioner or physician. Clinicians used 2way video conferencing and a high-resolution camera to examine residents and
prescribe treatments.
Researchers compared 2 years of outcomes from 6 nursing homes that used the
telemedicine service and 5 nursing homes that did not. They also categorized
nursing homes in the intervention group as “more engaged” or “less engaged,”
depending on how often they used the telemedicine service.
Grabowski, David and O’Malley, James. THE CARE SPAN: Use Of Telemedicine Can Reduce Hospitalizations Of Nursing Home Residents and Generate
Results?
Engaged Nursing Homes Reduce Hospitalizations
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Hospitalization rates dropped by 9.7% among nursing homes in the intervention group after
the telemedicine service began. Nursing homes in the control group reduced their
hospitalization rates by 5.3%.
There was a 11.3% decline in hospitalization rates at “more engaged” nursing homes in the
intervention group.
•
Researchers projected that nursing homes that were “more engaged” with telemedicine could
each save Medicare an average of $151,000 each year.
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Each telemedicine system costs $30,000 to install, implying a net savings of roughly $120,000
per nursing home per year in the more engaged facilities.
Increasing Access to Specialty Care: A Pilot, Randomized
Controlled Trial of Telemedicine for Parkinson’s Disease
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A study evaluated the feasibility of providing subspecialty care via telemedicine
for patients with Parkinson’s disease residing in a remote community located
130 miles from an academic movement disorders clinic.
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10 patients were randomized to receive telemedicine care with a movement
disorder specialist (n=6) or their usual care (n=4).
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Feasibility, as measured by the completion of telemedicine visits, was the
primary outcome measure. Secondary measures were quality of life, patient
satisfaction, and clinical outcomes.
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Four nursing home patients were assigned to telemedicine. Those receiving
telemedicine completed 97% (29 of 30) of their telemedicine visits as
scheduled.
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Compared with usual care, those randomized to telemedicine had significant
improvements in quality of life (3.4 point improvement vs. 10.3 point
worsening on the Parkinson’s Disease Questionnaire 39) and motor
performance (0.3 point improvement vs. 6.5 point worsening on the Unified
Parkinson’s Disease Rating Scale, motor subscale).
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Relative to baseline, nursing home patients experienced trends toward
improvement in quality of life and patient satisfaction. Providing
subspecialty care via telemedicine for individuals with Parkinson’s disease
living remotely is feasible.
Dorsey, E. R., Deuel, L. M., Voss, T. S., Finnigan, K., George, B. P., Eason, S., Miller, D., Reminick, J. I., Appler, A., Polanowicz, J., Viti, L., Smith, S., Joseph, A. and Biglan, K. M. (2010), Increasing
access to specialty care: A pilot, randomized controlled trial of telemedicine for Parkinson's disease. Mov. Disord., 25: 1652–1659. doi: 10.1002/mds.23145
ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term
Care Residents With Dementia and Behavioral Issues
In another study, a remote case-based video-consultation program called ECHO-AGE was used. It linked
experts in the management of behavior disorders in patients with dementia to nursing home care
providers.
Eleven long-term care sites in Massachusetts and Maine, presented challenging cases regarding residents
with dementia and/or delirium related behavioral issues to specialists via video-conferencing.
Baseline resident characteristics and follow-up data regarding compliance with ECHO-AGE
recommendations, resident improvement, hospitalization, and mortality were collected from the
long-term care sites.
Results: Forty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot
period. Eighty-three percent of residents had a history of dementia and 44% were taking
antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness,
and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication
adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed
in 88.6% of residents. When recommendations were followed, sites were much more likely to report
clinical improvement (74% vs 20%). Hospitalization was also less common among residents for whom
recommendations were followed.
TAKE HOME: case-based video-consultation program can be successful in improving the care of elders
with dementia and/or delirium related behavioral issues by linking specialists with long-term care
providers.
Catic AG, Mattison ML, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and
Behavioral Issues. J. Amer. Med. Dir. Assoc. [online before print], 2014
Effectiveness of telecare in elderly populations--a
comparison of three settings
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The primary aim of this study was to assess the level of satisfaction with 3 types of
formal care systems of the elderly:
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(1) a day care center,
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(2) a nursing home, and
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(3) telecare service in a group of oldest frail elderly,
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The study involved a population of 162 oldest elderly. Study participants were asked
to complete a questionnaire, investigating socio-demographic characteristics and
degree of overall satisfaction with the service, as well as eliciting possible
suggestions for improvement.
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In our study, nearly all subjects using the telecare service were satisfied or very
satisfied (98.5%), as compared to 75.3% of those residing in a nursing home, and
76.5% of those attending the day care center.
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This result confirms the findings of previous studies on elderly subjects' satisfaction
with telecare services. Telecare, therefore, seems to be the service achieving the
greatest levels of satisfaction, a service that can also be used by low-income
subjects, by whom it is also perceived as a source of social support.
Maria L. Onor, Marianna Trevisiol, Ornella Urciuoli, Shai Misan, Francesca Bertossi, Gabriella Tirone, Eugenio Aguglia, and Elisabetta Pascolo-Fabrici. Telemedicine and eHealth. March 2008, 14(2): 164-169. doi:10.1089/tmj.2007.0028
.
Benefits of Telepsychiatry Consultation
Service for Rural Nursing Home Residents
• Psychiatric care for NH residents is difficult to obtain, especially in rural areas, and
this deficiency may lead to significant morbidity or death.
• Providing this service by videoconference may be a helpful, cost-effective, and
acceptable alternative to face-to-face treatment.
• A study analyzed data for 278 telepsychiatry encounters for 106 NH residents to
estimate potential cost and time savings associated with this modality compared
to in-person care (REFER TO TABLE):
– A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to inperson consultation for each of the 278 encounters if they had occurred separately.
– Travel distance saved was 43,000 miles.
– More than $3,700 would be spent on gas for 278 separate encounters.
– Personnel cost savings estimates ranged from $33,739 to $67,477.
– Physician costs associated with additional travel time ranged from $84,347 to $253,040
for 278 encounters.
The point?
• Although telemedicine applications for the general population are
relatively widespread and numbers are increasing, less has been
accomplished specific to elders, though they are a major target group
for telemedicine interventions, who appear to benefit from and to
be accepting of a telemedicine approach to their needs.
• The tele psychiatry approach was enthusiastically accepted by
virtually all residents, family members, and NH personnel, and led to
successful patient management.
• In addition, this approach will allow many nursing homes to provide
essential care that would not otherwise be available.
Terry Rabinowitz, Katharine M. Murphy, Judith L. Amour, Michael A. Ricci, Michael P. Caputo, and Paul A. Newhouse. Telemedicine and e-Health. January/February 2010,
16(1): 34-40. doi:10.1089/tmj.2009.0088
Long term effect of home telehealth services on preventable
hospitalization use
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In this study, the longitudinal effect of a Department of Veterans Affairs (VA)
patient-centered Care Coordination Home Telehealth (CCHT) program on
preventable hospitalization use by veterans with diabetes mellitus (DM) at four VA
medical centers was assessed.
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All patients were followed for 4 years.
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During the initial 18 months of follow-up, CCHT enrollees were less likely to be
admitted for a preventable hospitalization than their non-enrollee counterparts,
and this difference diminished during the rest of the 4-year follow-up period.
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The VA CCHT program for DM patients reduced preventable hospitalizations. These
findings are some of the first that have systematically examined the extent to which
home telehealth programs have a long-term effect on preventable hospitalization
use.
Jia, H; Chuang, HC; Wu, SS; Wang, X; Chumbler, NR. Long-term effect of home telehealth services on preventable hospitalization use. J Rehabil Res Dev.
2009;46(5):557-66.
Today
>16,000+ patients
enrolled in daily home
telehealth with Health
Buddy
Over 100 programs
for 30+ chronic
conditions
FEB 2006
This is new...
Remote monitoring of NH residents using
a humanoid robot
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Assistive robots have been used in elderly care to support NH staff in their daily activities.
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The tasks carried out by the robots included:
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Improving drug compliance
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Increasing physical exercise adherence
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Acting as a substitute for a companion animal
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Assisting in different kinds of rehabilitation tasks
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The robot can receive alarms via its wireless Internet connection and navigate independently to the room
where the alarm originated. It would transmit near real time images to the staff and also open a voice
connection between the resident and the remote caregivers.
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This allows the staff of the monitoring center to check the resident’s condition and take appropriate action.
Bäck, Livari; Kallio, Jouko; Perälä, Sami; Mäkelä, Kari. Remote monitoring of nursing home residents using a humanoid robot. J Telemed Telecare. September 2012 18: 357-361,
doi:10.1258/jtt.2012.120305
General consensus
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Hui et al1 found when a telemedicine service was gradually implemented for nursing home residents
(NHRs), adequate care delivery occurred in 99%, more residents were served, and follow-up intervals
were shortened, and the intervention was associated with a 9% reduction in Emergency Department
(ED) visits and an 11% reduction in admission to acute care hospitals
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Chae et al2 reported a high rate of patient satisfaction with telemedicine and that its use was
associated with significantly fewer monthly clinic visits.
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Noel et al3 found that elders with complex comorbid medical conditions who received care via
telemedicine had significantly lower rates of days in bed and urgent or ED visits and higher satisfaction
rates.
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Tsuji et al4, Jerant et al5, and Brownsell et al6, suggest that telemedicine for elders has the potential to
significantly reduce overall healthcare costs and morbidity.
1) Hui E, Woo J, Hjelm M, Zhang YT, Tsui HT. Telemedicine: A pilot study in nursing home residents. Gerontology 2001; 47:82-87.
2) Chae YM, Heon Lee J, Hee Ho S, Ja Kim H, Hong Jun K, Uk Won J. Patient satisfaction with telemedicine in home health services for the elderly. Int J Med Inf 2001; 61:167-173.
3) Noel HC, Vogel, DC, Erdos JJ, Cornwall D, Levin F. Home telehealth reduces healthcare costs. Telemed J E Health 2004;10:170-183.
4) Tsuji M, Miyahara S, Taoka F, Teshima M. An estimation of economic effects of tele-home-care: Hospital cost-savings of the elderly. Medinfo 2001;10(Pt 1): 858-862.
5) Jerant AF, Azari R, Nesbitt TS. Reducing the cost of frequent hospital admissions for congestive heart failure: A randomized trial of a home telecare intervention. Med Care 2001;39:1234-1245.
6) Brownsell SJ, Bradley DA, Bragg R, Catling P, Carlier J. an attributable cost model for a telcare system using advanced community alarms. J Telemed Telecare 2001;7:63-72.
STAY HOME Project – Background
(Strategic Team Activity Yielding High Outcomes and Minimizing Expenditures)
• Many avoidable ED visits and hospitalizations
occur among NH residents
• These visits lead to increased health care costs
and affect the quality of care and life for the
residents
• The first step in addressing the problem is to
determine the root cause
STAY HOME - Purpose
• Purpose of this project was to
determine the rate and
characteristics of avoidable
transfers of NH residents to
acute care (hospitalization)
STAY HOME - Method
• This project is the first phase of the STAY HOME
project establishing baseline data
• Two facilities provided transfer lists for each month
(January -July 2014)
• The data included reason for transfer from NH to
acute care (hospitalization), date of transfer and the
discharge diagnosis
STAY HOME - Methods (Contd.)
• Chart review was completed on 29%
(N=44) of the 151 of these transfers
using the INTERACT Quality
Improvement Tool
INTERACT 3 Quality Tool
Results
• 151 residents were transferred during
the 7 month period at the 2 facilities
(site 1 =87; site 2=64)
• Over ¼ of the transferred residents were
categorized as at-risk for transfer, as a
result of multiple co-morbidities and
polypharmacy
Results
Unplanned hospitalization rates for
the 2 facilities for the 7 month period
was:
• Site 1: 4.42 admissions every 10
days
• Site 2: 2.55 admissions every 10
days
Table 1. Primary Reasons for
Transfer
Reason for Transfer
N=
%
Respiratory Distress
Abnormal vital signs
AMS
Abnormal labs
Fever
GI bleed
Chest pain
Pain (other than chest pain)
Other
33
13
12
12
10
8
7
6
50
21.8%
8.6%
7.9%
7.9
6.6%
5.3%
4.6%
3.97%
33.1%
Figure 1. Number of Transfer per Month for
Both Sites
Figure 2. Number of Transfers per Day of Week for Both Sites
Conclusions
• Further exploration of the potential use of tele-health for
assessment and management of acute changes in condition
is essential
• Telemedicine is a feasible and potentially beneficial means
for increasing access to specialty care for a large and
growing population.
• Future research should focus on how to adapt systems to
the individual needs (deficit in cognitive function, physical
limitation and comorbidities) and resources of elderly
patients within the specific frameworks of the respective
national healthcare systems
We will be using...
HNC IT Support: 248-926-1661
Medical Peripherals include...
The Laurels
Virtual Clinic:
•
Login: UOT1
•
Password: UOT1Host
Link:
•
https://ausv5.omnijoin.com/join?dn=UOT1&password=UOT1Host&product=OmniJoin&versi
on=6.0.40.629&pfpath=Brother%5COmniJoin&setup=ccsetup.exe&shellexec=CC\
CC.exe
Stethoscope
Login 1 (patient side): LA1
Login 2 (clinician side): LA2
Password 1: Toledo123
Password 2: Toledo123
Patient Data Center
•
Login: UOT1
•
Password: UOT1doc
Virtual Clinic:
•
Login: UOT2
•
Password: UOT2Host
Wolf Creek:
Link: https://ausv5.omnijoin.com/join?dn=UOT2&password=UOT2Host&product=OmniJoin&version
=6.0.40.629&pfpath=Brother%5COmniJoin&setup=ccsetup.exe&shellexec=CC\CC.exe
Patient Data Center:
•
Login: UOT2
•
Password: UOT2doc
Stethoscope
Login 1 (patient side): WC1
Login 2 (clinician side): WC2
Password 1: Toledo123
Password 2: Toledo123
•
Patient Data Center: https://healthco.nexcess.net/wipam
•
Stethoscope: https://www.littmann.com/telemedicine/launch
Lutheran Home at Toledo:
Virtual Clinic:
• Login: UOT3
• Password: UOT3Host
Link: https://ausv5.omnijoin.com/join?dn=UOT3&password=UOT3Host&product=OmniJoin
&version=6.0.40.629&pfpath=Brother%5COmniJoin&setup=ccsetup.exe&sh
ellexec=CC\CC.exe
Patient Data Center:
• Login: UOT3
• Password: UOT3doc
Stethoscope
Login 1 (patient side): XX1
Login 2 (clinician side): XX2
Password 1: XXXX123
Password 2: Toledo123
• Patient Data Center: https://healthco.nexcess.net/wipam
Stethoscope: https://www.littmann.com/telemedicine/launch
Discussion - Are you involved?
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Audience - Any previous experiences with telehealth?
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Reluctance - and reasons
•
Can our society afford not to bring telehealth into our
healthcare management situations?
RESOURCES
 Telehealth Resource Centers Toolkits
 •http://www.telehealthresourcecenter.org/toolbo
x.php
Thank You